Runway incursion involving a Boeing 767-338ER, VH-OGK, Brisbane Aerodrome, Queensland, on 7 February 1998

Summary

Prior to issuing a take-off clearance the controller checked that the runway was clear. Take-off was rejected when the crew of VH-OGK saw a vehicle on a taxiway and entering the runway. The aircraft exited via the next available taxiway and returned to the runway end for an uneventful departure.

A pest control contractor had been escorted to an aircraft parking area on the domestic apron to fumigate a number of aircraft. He was also informed that another aircraft to be treated was in the maintenance hangar on the other side of the airport. He indicated that he would travel to the hangar via the public roads outside the airport and that he would leave the airport via Gate 1, through which he had entered. He also indicated that he knew the location of the airline's operations office. No airline supervision was provided while the contractor did his work.

On completion of the work on the apron the contractor decided to travel to the hangar via the perimeter road inside the airport. He ultimately arrived at the hangar and completed the task there. No supervision was provided by hangar staff as they were not aware the contractor did not have an airside licence. The contractor departed the hangar intending to return to gate 1 via the perimeter road. While driving along the taxiway from the hangar he missed the turn to the perimeter road and crossed the holding point to the runway. This was when the aircraft crew observed the vehicle and rejected the take-off. A short time later, the vehicle was intercepted by an airport safety officer.

Procedures required that all persons who do not hold an 'Airside Drives Authority' be escorted and supervised at all times while airside. This requirement was not complied with in this instance. As an additional safety measure, a 'Safety Information Note' has been prepared for issue to all airside visitors.

Occurrence summary

Investigation number 199800460
Occurrence date 07/02/1998
Location Brisbane Aerodrome
State Queensland
Report release date 22/06/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-338ER
Registration VH-OGK
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane Qld
Destination Bangkok, Thailand
Damage Nil

Passenger related involving a Boeing 747-238B, VH-EBQ, 800 km north-east of Sydney Aerodrome, New South Wales, on 2 February 1998

Summary

The cabin service manager came to the flight deck to advise the pilot in command of an intoxicated passenger who was in the galley and making intimidating threats towards three flight attendants. The pilot in command was then advised that the passenger had punched two other passengers.

A short time later, the pilot in command was informed that a female passenger was alleging that she had been indecently assaulted by the passenger. The pilot in command directed that the passenger be restrained and requested that Police meet the aircraft on arrival at Sydney.

On arrival at Sydney, the passenger was arrested, charged with assault and subsequently sentenced to 6 months jail.

Occurrence summary

Investigation number 199800447
Occurrence date 02/02/1998
Location 800 km north-east of Sydney Aerodrome
State New South Wales
Report release date 14/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-238B
Registration VH-EBQ
Sector Jet
Operation type Air Transport High Capacity
Departure point Honalulu Hawiia USA
Destination Sydney NSW
Damage Nil

Operational non-compliance involving a Boeing 767, JA8970, 6 km south-east Sydney Aerodrome, New South Wales, on 9 February 1998

Summary

The Boeing 767 had departed from runway 16R at Sydney, NSW and the crew were tracking via a GUEST 2 standard instrument departure (SID) with an initial altitude restriction of 5,000 ft. The SID required the aircraft to track via the 163 radial of the Sydney very high frequency omni-directional radio range beacon (VOR) for 10NM before turning right to track for Glenfield. On first radio contact with Departures Control, the crew were instructed to climb to flight level (FL) 280 but, incorrectly, read back "to heading 280" and commenced a turn to the right when approximately 2 NM south of the runway.

The air traffic controller did not realise that the crew had read back heading 280 and replied using the word "affirm". He also re-iterated the instruction to climb to FL280, which the crew correctly read back. This situation resulted in the crew believing that they had been cleared to climb to FL280 and to turn right to Glenfield, while the controller believed that the crew were climbing to FL280 via the SID track. The turn was observed on radar and, although there were several other aircraft in the general area, radar vectors by air traffic control ensured that no breakdown of separation standards occurred.

Occurrence summary

Investigation number 199800444
Occurrence date 09/02/1998
Location 6 km south-east Sydney Aerodrome
State New South Wales
Report release date 21/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767
Registration JA8970
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Kensai Japan
Damage Nil

Wheels up landing involving a Cessna 210L, VH-TCR, Darwin Aerodrome, Northern Territory, on 11 February 1998

Summary

When the pilot selected the landing gear down he found that the gear was not indicating down. He could see that the main gears were extended and the control tower confirmed that the nose gear was not extended. The pilot diverted to a clear area and gained altitude to conduct further attempts to lower the landing gear. All attempts were unsuccessful. A landing was later conducted on the main gears, with the pilot shutting down the engine during the landing roll prior to the aircraft settling on its nose.

Examination of the nose landing gear found that a pin had fallen from a shaft associated with the uplock mechanism. As a result, the nose gear was locked up, with no way to release the lock. The pin was recovered when the aircraft was lifted. The reason for the pin becoming loose has not been established. It is located in an area which cannot be checked during a daily inspection. The aircraft had flown about 65 hours since the previous periodic inspection.

Occurrence summary

Investigation number 199800430
Occurrence date 11/02/1998
Location Darwin Aerodrome
State Northern Territory
Report release date 23/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210L
Registration VH-TCR
Sector Piston
Operation type Charter
Departure point Peppimenarti NT
Destination Darwin NT
Damage Substantial

Collision with terrain involving a Cessna A188B/A1, VH-DDW, Jandowea, Queensland, on 12 February 1998

Summary

The aircraft was conducting spraying operations in a paddock bounded by a power line. Due to the nearness of the paddock to the power line, it was necessary for the pilot to fly the aircraft under the line at the commencement of each spray run. At the beginning of the accident run, the pilot rolled the aircraft right to clear a small tree. As he did this, the left wing contacted the power line. The aircraft then rolled inverted and struck the ground left wing first, cartwheeling several times before coming to rest inverted. The pilot was able to exit the aircraft before fire consumed the majority of the wreckage.

The pilot confirmed that the aircraft was operating normally at the time of the accident. While maneuvering to avoid the small tree, he had momentarily forgotten about the power line and did not correct quickly enough to prevent the wing contacting it.

Occurrence summary

Investigation number 199800421
Occurrence date 12/02/1998
Location Jandowea
State Queensland
Report release date 23/03/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model A188B/A1
Registration VH-DDW
Sector Piston
Operation type Aerial Work
Departure point Kapunn, near Jandowea Qld
Destination Warra - Janoowie Qld
Damage Destroyed

Electrical systems involving a Boeing 767-204, VH-RMO, 222 km north-north-east of Melbourne Aerodrome, New South Wales, on 12 February 1998

Summary

Approaching the top of the climb out of Melbourne, enroute to Brisbane, the Boeing 767 suffered a standby DC bus failure. The crew elected to return to Melbourne.

Investigation by the operator discovered a faulty circuit breaker. The circuit breaker was replaced and the standby system functionally tested as serviceable. The aircraft was then returned to service.

Occurrence summary

Investigation number 199800417
Occurrence date 12/02/1998
Location 222 km north-north-east of Melbourne Aerodrome
State New South Wales
Report release date 11/05/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-204
Registration VH-RMO
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Brisbane Qld
Damage Nil

Air-ground-air involving a Airbus A310, 9V-STA, 93 km north-west of BIDAP, Western Australia, on 4 February 1998

Summary

The crew of the foreign registered Airbus A310 were maintaining the aircraft at FL370 on air route A585 and were estimating the BIDAP position at 0234 WST. BIDAP was the boundary between the Perth and Melbourne Air Traffic Control areas of responsibilities and Perth Sector Control had instructed the crew to contact Melbourne Sector Control at BIDAP. As their aircraft approached BIDAP, the crew observed a weather return on radar along their proposed track just passed the reporting point.

The crew decided to make a diversion to the north, left of track, to avoid the storm. As they were approaching BIDAP, the pilot-in-command commenced a 15-degree track change and instructed the co-pilot to advise Melbourne Sector that a diversion to the left was required. The co-pilot made a radio transmission to Melbourne Control indicating their position as abeam BIDAP and "up to 15NM left of track due weather". The aircraft was actually only 2 - 3NM off track at that time. Melbourne Control replied with an instruction for the crew to limit their diversion to 15NM due to conflicting traffic. A short time later, Melbourne Control informed Perth Control that the crew had reported 15 NM left of track due weather and established that this diversion had not been requested by the crew from either Melbourne or Perth Control.

Melbourne Control were able to ensure separation from an Australian registered Boeing 747 that was on a conflicting air route. The tracks were laterally separated at the point at which the A310 crew reported their position, and the direction of travel ensured that the aircraft were diverging. The co-pilot believed he was reporting the position at BIDAP with a request for a diversion left of track and believed that the response from Melbourne Control was a clearance to conduct the diversion. Melbourne Control believed they were limiting the possibility of conflict for a diversion that had already taken place.

The co-pilot's first language was not English and this may have contributed to a misunderstanding between the controller and the crew It was not established at which point the crew of the A310 commenced their diversion but, as the crew reported that it was only "a few miles prior to BIDAP", it was probably outside the lateral separation points for the two routes and, therefore, no infringement of the separation standards was likely to have occurred.

Occurrence summary

Investigation number 199800416
Occurrence date 04/02/1998
Location 93 km north-west of BIDAP
State Western Australia
Report release date 21/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Air-ground-air
Occurrence class Incident

Aircraft details

Manufacturer Airbus
Model A310
Registration 9V-STA
Sector Jet
Operation type Air Transport High Capacity
Departure point Singapore
Destination Adelaide SA
Damage Nil

Weather - Other involving a Boeing 747-438, VH-OJR, Melbourne Aerodrome, Victoria, on 5 February 1998

Summary

FACTUAL INFORMATION

The aircraft departed Auckland for a scheduled flight to Melbourne. Weather forecasts available to the crew indicated that the weather at the estimated arrival time of 2210 UTC would be a variable wind of 5 kts and CAVOK conditions. A trend type forecast (TTF) was issued at 2000 and indicated that the wind was calm with 1 okta of cloud at 1,000 ft.

The forecast was appended with the term NOSIG which indicated that there was no significant change due in the next 3 hours. The automatic terminal information service at 2109 indicated that the cloud now was 6 oktas at 400 ft with lower patches and that the visibility was 4,000 m in fog. The aircraft at this time was past the point at which it could divert to an alternate aerodrome. A special weather report (SPECI) was issued at 2130 and indicated that the cloud would be 7 oktas at 200 ft and that the visibility would still remain at 4,000 m.

These conditions were below the alternate minima for the airport, and the aircraft was not carrying additional fuel to divert. The aircraft landed uneventfully at 2214 after becoming clear of cloud at the minimum altitude with an estimated visibility of 800 m.

ANALYSIS

A report from the Bureau of Meteorology indicated that a number of local conditions contributed to the incident. There was an area of low cloud that was situated over the centre of Melbourne city and this did not extend to the airport.

The dewpoint in the area was considerably higher than normal at 14 degrees. The layer of cloud was thin and was expected to be eroded by the sun. However, it had risen considerably and commenced surface heating. There was also a northerly wind at approximately 5 kts and this was thought to assist in keeping the cloud to the south of the airport and over the city.

However, a weak eddy formed and forced the cloud layer to move to the north and the base to become considerably lower than first forecast. A similar meteorological situation was present a few days after the occurrence and in that case, no cloud formed at the airport.

Occurrence summary

Investigation number 199800411
Occurrence date 05/02/1998
Location Melbourne Aerodrome
State Victoria
Report release date 14/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Weather - Other
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-438
Registration VH-OJR
Sector Jet
Operation type Air Transport High Capacity
Departure point Auckland New Zealand
Destination Melbourne Vic.
Damage Nil

Weather - Other involving a Boeing 767-238, VH-EAO, 37 km west-south-west of Sydney Aerodrome, New South Wales, on 15 January 1998

Summary

The Boeing 767 departed Melbourne at approximately 0640 UTC for a scheduled flight to Sydney. The aircraft had an estimated arrival time at Sydney of approximately 0725. The crew had been given the Terminal Area Forecast (TAF) issued at 0000 and the Trend Type Forecasts (TTFs) issued at 0100 and 0430 at flight planning and these indicated that the visibility would be in excess of 10 km and the cloud base would be mostly above 2,500 ft. The routine meteorological report (METAR) which was issued at 0600 indicated that visibility would be reduced to 9,000 m in haze and that the lowest cloud base would be 4 oktas at 1,500 ft.

The crew received this forecast by the aircraft communication addressing and reporting system (ACARS) during the pre-flight preparation at Melbourne. A terminal area forecast was issued at 0606 and this indicated that the cloud base would be 3 oktas at 1,000 ft. Another METAR was issued at 0630 and this indicated that the cloud would be 1 okta at 1500 feet with 7 oktas at 1,800 ft. The visibility on this report was indicated to be in excess of 10 km. A further METAR was issued at 0700 and this indicated that the cloud base would be 3 oktas at 1,400 ft, with further cloud of 7 oktas at 1,800 ft. The visibility, however, had decreased to 8000 m in drizzle. This forecast had the term NOSIG appended to it indicating that there was no significant change expected within the next 3 hours.

A special weather report (SPECI) was issued at 0717, which indicated that the cloud base had lowered to 2 okta at 900 ft and that the visibility had decreased to 6,000 m in drizzle and mist. Coincident with the issuing of this report, a TTF was issued and this forecast was appended with the term INTER which indicated that for periods of up to 30 minutes during the validity period of the forecast the visibility would decrease to 6,000 m and that the cloud base would be 2 oktas at 1,000 ft with further cloud of 7 oktas at 1,500 ft. On arrival in the Sydney terminal area, the aircraft received the automatic terminal information service (ATIS), which indicated that the visibility had reduced to 4,000 m in rain and that the cloud base had lowered to 800 ft.

This weather was worse than that which the crew had expected from the forecasts. The aircraft landed uneventfully at 0724. A report from the Bureau of Meteorology (BOM) indicated that the weather conditions were consistent with the passage of a southerly change that had passed through Sydney approximately 2 hours prior to the aircraft departing Melbourne. Forecasts issued by BOM over the period from 0600 to 0717 indicated a gradual decrease in the visibility and a lowering of the cloud base. All of these forecasts were available to the crew in flight on a request basis.

The ATIS for the period from 0655 to 0713 also indicated that the cloud base was gradually lowering and that the visibility was decreasing. The crew would also have had this information available to them in flight. Forecasts issued by BOM were based on observations from trained weather observers situated at Sydney airport as well as output from a number of weather stations around the Sydney area and throughout the country. It also took into account predictions from the numerous computer programs available to BOM. Because of the time taken to analyse all the available data, there was a time delay in updating the weather forecasts.

The ATIS provided by personnel in the control tower at Sydney airport is based largely on visual observation of the conditions prevailing at the airport at the time. As control over the issuing of the ATIS rested with the personnel in the control tower, changes to the information could have been made almost instantaneously. The time delay experienced could be observed with BOM's issue of another SPECI at 0730, indicating that the cloud base had lowered even further. Even though there were only 13 minutes between the two SPECI reports, it was during this time that the incident aircraft, as well as others, landed.

Occurrence summary

Investigation number 199800408
Occurrence date 15/01/1998
Location 37 km west-south-west of Sydney Aerodrome
State New South Wales
Report release date 11/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Weather - Other
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-238
Registration VH-EAO
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Sydney NSW
Damage Nil

Wheels up landing involving a Beech Aircraft Corp A36, VH-FIM, Canberra Airport, Australian Capital Territory, on 7 February 1998

Summary

The aircraft departed Canberra for Merimbula on a VFR flight with a departure instruction to remain on the Tower frequency. A short time after departure, ATC instructed the pilot to call Approach, but there was no reply. The aircraft was then observed to make a right turn to intercept the outbound track to Merimbula although no transponder return was being interrogated. The aircraft was subsequently observed orbiting over the Googong reservoir.

ATC tried unsuccessfully to make radio contact. Shortly after, the aircraft was observed to be returning to the airport for an approach to runway 30. On finals it was evident that the landing gear was not fully extended and a full aerodrome emergency was declared. The aircraft then made a low fly pass and the tower observation confirmed that the landing gear was not down and locked.

The aircraft subsequently made a wheels up landing on the grass parallel to runway 30. When the aircraft came to rest, the sole occupant walked clear of the aircraft. During the maintenance investigation, the landing gear retraction system components were tested and found to be serviceable. The aircraft battery was found to be fully discharged.

Occurrence summary

Investigation number 199800386
Occurrence date 07/02/1998
Location Canberra Airport
State Australian Capital Territory
Report release date 20/05/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model A36
Registration VH-FIM
Sector Piston
Operation type Private
Departure point Canberra ACT
Destination Merrimbula NSW
Damage Substantial